My Guidelines for care of a woman expecting Twins

Antenatal care

Depending on the gestation when the diagnosis of the twin pregnancy is made, the following should be discussed with the woman, and her partner if appropriate.

Nutrition and Diet

I find it helpful to ask the woman to keep a diet diary for a few days, including a weekend day. I then go through the diary with her identifying whether there is an adequate intake of :

  1. Calories with a good balance of carbohydrate protein and fat
  2. Adequate vitamins
  3. Adequate sources of the important minerals and trace elements.

If we identify any deficiencies we discuss ways of improving nutrition. I stress the importance of eating well.

Exercise and rest

We discuss lifestyle and any adjustments that should be made. I take the opportunity to inform the woman of any appropriate groups, classes or support organizations that she may care to join.

The place of birth

I explore with the woman her wishes and feelings on this subject and inform her of the options open to her in her geographic area. Should the woman choose to give birth to her babies in hospital, I would inform her of her rights to decide who will be in attendance during her labour and at the births. I would tell her that the practitioners attending her can give her advice, but have no power to stop her eating or drinking, if she feels like doing so, nor have they any power to restrict her movements or insist on being present. In fact her rights are exactly the same as they would be at home.

Depending on the gestation I discuss with the woman the advantages of having an ultrasound scan to determine chorionicity. Should she agree, with that information gained, I discuss the increased risks of a twin over a singleton pregnancy. I point out that while most twins are fine there are increased risks, and that the risks are greater if the twins are monozygotic (identical).

Depending on how much the woman wants to know at each consultation, I try to ensure that she understands that the labour could be preterm and that she is at increased risk of pregnancy-induced hypertension. This is a good time to discuss some forward planning, and that she should try to ensure that there are relatives, friends, available to help with other children, shopping cooking, housework etc in the latter part of the pregnancy, and in the first month or so after the births. In my experience dizigotic twins often go to term, and the woman really needs domestic support as she is big and ungainly, and easily tired. She may find an abdominal supportive garment helpful or support tights may help as there is an increased risk of varicose veins.

I encourage her to monitor her babies' growth by the feel of her clothing, particularly from 28 weeks or so. I ask her to observe how her clothes are getting tighter. I ask her to let me know if she does not notice increased girth, and also to inform me urgently if she observes a dramatic increase in girth; this is particularly important in monozygotic twins.

I plan to see her at frequent intervals, but make sure she feels able to access me, or my locum, if she has any concerns. In my experience women who are encouraged to monitor growth and how they feel, are very good at recognizing deviations from normal. Though while women should be encouraged to take some responsibility for their health, this does not relieve the professional attendant from vigilant care.

There should be a full discussion of the labour, what the attendants will want to do, and what the woman and her partner feel that they will want. A tentative plan for labour should be made and updated as necessary. This should include discussion of various birth positions.

If the woman is having midwife-only care the following list, which is not exclusive, are reasons to seek appropriate medical input:-

The Labour

Most twin labours progress well. The woman should be supported in the way that is most appropriate for her and that has been planned.

If a hospital labour has been chosen, I feel that it is good practice to do a 20 minute or so CTG trace of the fetal hearts in early labour, taking great care to ensure that one is actually recording two heart beats and not just hearing the same heart in two different places. This is an easy mistake to make with a CTG monitor if the twins are monozygotic, as the heart rates can be very similar. Even if a CTC monitor is used there should also be auscultation by two practitioners using two Pinards stethoscopes simultaneously. They will be listening in different places and this can corroborate the opinion that there are two fetal hearts.

In the home situation, the twins' hearts should be auscultated at frequent intervals. The midwife will have "got to know" these babies during her antenatal care. I suggest listening every 20 minutes or so in early labour, increasing the frequency as the labour progresses. If the membranes rupture, the heart sounds should be listened to immediately, and every 10 minutes or so thereafter, preferably just as a contraction is going off.

Maternal observations of pulse temperature and blood pressure and urinalysis should be made at the onset of labour, and I suggest that the maternal pulse should be felt at frequent intervals throughout, usually at the time one is listening to the FHs .

The woman should be encouraged to maintain an intake of nourishing fluids of her choice, and in early labour if she feels hungry she should have what she fancies to eat. Small nourishing easily digested snacks are usually preferred. In the latter part of the first stage when contractions are frequent and strong, few women want to eat, but most will want to drink water, This should be facilitated. She should be encouraged to rest and keep her batteries charged in early labour but should be encouraged to mobilize if that is what she wants as labour progresses and intensifies.

Vaginal examination should be performed if the membranes rupture and as the attending professional feels the need. The reasons for VE examination should of course always be explained and consent gained.

The midwife will know what the woman's veins are like as she will have taken blood during the pregnancy. If the woman's veins are difficult to access the insertion of a venflon should be considered and discussed with the woman

The Births

There should be three competent practitioners present who have rehearsed their roles.

Provision should be made to resuscitate two babies. In the hospital setting two resuscitaires should be available in the birth room or immediately adjacent . At home two resuscitation stations should be set up with heated pads, bags and masks, airways and 02 available.

There should also be the usual provision to deal with excessive post-partum blood loss from the mother.

During the second stage the woman is encouraged to assume whatever position she finds easiest. As the presenting part becomes visible and the birth of twin 1 is imminent I encourage the woman to assume a hands and knees position. If this feels wrong for her she should be assisted to whatever position she feels is right for her.

I suggest the following roles for the three attendants, whom I call midwives A, B and C:-

Mw A assists the mother to birth twin 1

Mw B is ready to receive twin 1 if resuscitation is required; it rarely is. Twin 1 goes into mother's arms and is assisted to suckle by MwB

Mw C assists Mw A to help the mother to recline and palpates the abdomen to ascertain the lie of twin 2. She auscultates the FH and reports her findings to Mw A. Sometimes the FH of Twin 2 is slow. If it is above 110 , there is little cause for concern, it usually picks up quickly. Mw C auscultates as frequently as possible.

If there is a transverse lie Mw A and Mw C attempt to massage the head down. This often happens spontaneously with the return of contractions.

If the lie remains transverse (this is highly unlikely in the primigravida), Mws A and C do an external and possibly internal podalic version.

Once the lie of twin 2 is longitudinal the return of contractions is patiently awaited and the mother continues to suckle twin 1.

FH auscultation frequently.

Once contractions resume Mw B is available to take Twin 1 if the mother needs to use her arms to push, or the father may cuddle his baby.

The mother is encouraged to push with the contractions and may need to have Mw C place her open hands on the maternal abdomen to brace the abdominal muscles. I like the mother to be in the all fours position so that if the presentation is breech, I have the access and room to assist the birth if appropriate.

The second sac of membranes may rupture spontaneously; if they do not, they may be ruptured when the presenting part of twin2 is below the ischial spines, or seen or felt at the vulva.

Mw A assists the birth of twin 2 and Mw C takes twin 2 and is ready to resuscitate if necessary. Second twins often need some help to breathe and usually a few minutes of bag and mask is sufficient. The parents welcome their babies and everybody gets their breath back.

While Mw B's priority is the care of twin 1 this baby is usually in good condition and Mw B is available to give assistance where needed. However provision must be made for Mw B to be fully occupied with twin 1

The 3rd stage is managed as the midwives and the woman have agreed. I usually use expectant management but many midwives will prefer to actively manage the 3rd stage. When expectant management is used and the signs of placental separation and descent are noted, the mother may need to have her abdomen supported by the midwife's outstretched hands as she pushes the placenta out. It is important to have oxytocic drugs checked and readily available. If active management of the 3rd stage is chosen controlled cord traction is applied to both cords simultaneously once the oxytocic drug has taken effect.

Reasons to seek medical consultation/assistance/ input, or advise transfer to hospital if at home.

At the onset of the labour

  1. If there is any concern about the condition of either baby, suboptimal fetal heart sounds and rates.
  2. In a primigravida if the presenting twin is not a longitudinal lie and the presenting part is not engaged. In a multigravida if the lie is not longitudinal or if presenting part is high and does not engage as the contractions strengthen.
  3. If there is a raised blood pressure or fever or maternal tachycardia.
  4. If there is any excessive vomiting which does not respond to simple measures.
  5. If there is any abnormality in urinalysis.
  6. If the midwife has any concerns she should be able to discuss them with a Medical colleage or her supervisor of midwives.

During the Labour.

  1. If the labour does not progress well. ie if the contractions once established do not come oftener last longer get stronger. If the presenting part does not descend. And if the cervix does not efface and dilate
  2. If there is any concern about the fetal or maternal condition.
  3. If the lie of twin 2 is not longitudinal and a version is not easily accomplished.

I feel it is good practice if the woman is at home to inform the hospital to which one would transfer if indicated, that the woman's labour has started. The midwife might wish to keep the hospital staff informed of the progress of the labour. This will depend on geography and local circumstances. Good relationships between professional colleages are always extremely important and especially so in the case of twins.

Mary Cronk

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